Horseman's Assistance Fund Application

Date of Application*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Contact Person*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Does applicant have a family or business relationship with any USHJAF Officer or Board Members?*

YesNo

Please explain

Brief description of request*

Amount of Request *

List any previous or current support from the USHJA Foundation, United States Hunter Jumper Association and/or American Hunter Jumper Foundation. If there are none, please indicate by writing “None” below:*

Please include date, amount and purpose for any previous support

List any previous or current support you have received from other assistance organizations or entities. If there are none, please indicate by writing “None” below:*

Please include date, name of org/entity, amount and purpose for any previous support

Applicants must disclose and all source(s) and amount(s) of short-term or long-term disability assistance (Worker’s Compensation, disability insurance claims, Social Security, etc.) If there are none, please indicate by writing “None” below:*

Please include date, name of org/entity, monthly amount and total amount expected for any previous support

If there are currently none, do you expect to begin receiving disability assistance any time within the next twelve (12) months?If so, please indicate when and from what entity/organization(s):

Please include date, name of org/entity, monthly amount and total amount expected for any previous support

Have you reviewed the application procedures and included all requested information along with this application?*

YesNo

Please list any outstanding documents and when they will be submitted

List outstanding documents and estimated submission date.

May we use information about your case in our fundraising efforts?*

YesNo

By circling YES you are giving the USHJA Foundation and the USHJA permission to use your story in promotional and marketing efforts. Efforts may include use of photos, video and press releases on your story that may appear in print and online promotion of the assistance you received.

Should your application be accepted and assistance granted and you have circled YES on this form, a separate media release form may be forwarded to you for completion.

The following materials must accompany every application:

A typed letter detailing the emergency situation and the impact it has had on the applicant’s current financial situation and/or reason for emergency funding.
Financial statements substantiating the request for assistance, including a list of assets and two (2) years of most recently filed tax returns with all applicable schedules attached.
A letter from a licensed physician attesting to the disability.
If requesting assistance to offset loss of income, please provide an estimated timeline of need for the financial support.
If requesting assistance to support your monthly living expenses, please supply copies of statements, invoices, or other documentation to substantiate your monthly expenses.
Provide two letters of reference from USHJA members who can verify your involvement with the hunter/jumper sport and can attest to your need for financial assistance. These letters must be received from the authors andform letters are not acceptable.

File Upload*

By signing below, I acknowledge and agree that the information contained in my application and supporting materials is accurate and true. I further acknowledge and agree that if any information has been fraudulently submitted, USHJA Foundation reserves all rights to deny this application and pursue any and all appropriate remedial action, including legal remedies.

Signature*

Signature of parent or guardian if applicant is under 18

Date*

Date

Printed Name

Printed Name of Parent or Guardian